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General NPI Number Information
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NPI Number | 1336120344
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Entity Type | Individual
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Provider Name | MICHAEL STACEY M.D.
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Gender | Male
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Dates
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Enumeration Date | 11/07/2005
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Last Update Date | 02/20/2008
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Provider Practice Location Address
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Address Line | 275 BECK AVE MS 5-240
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City | FAIRFIELD
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State | CA
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Zip | 94533-6804
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Country | US
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Telephone | 707-784-8600
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Fax | 707-421-6618
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Provider Business Mailing Address
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Address Line | 102 SAN CARLOS AVE
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City | EL CERRITO
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State | CA
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Zip | 94530-4149
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Country | US
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Telephone | 707-784-8600
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 01057967A
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License Number State | IN
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